1. automotive and vehicles
2. campers and rvs

REACH OUT AND TOUCH SUMMER CAMP REGISTRATION FORM
How to register your child -­‐ don’t be disappointed, camps fill quickly -­‐ register early Four groups (Ages 4, Ages 5-­‐7, Ages 8-­‐10, Ages 11-­‐14)
1. Complete both sides of this form and drop off or mail with one 4me registra4on fee of $25 to Reach Out and Touch, Post Office Box 3966, Shreveport, LA 71133. You will receive a confirma4on (phone or email) within one week of receipt of registra4on. If you do not hear from us, please call 318-­‐210-­‐8352 or 318-­‐682-­‐3850. We will only accept 100 children. Payment of registra4on and ac4vity fee will secure your child a place in this camp. Registra4on fees are non-­‐refundable.
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2. Camp fees are $110. If your child qualifies for the sliding fee discount, rates are $55 per week, 2 child -­‐ $45, 3 child $35. A one-­‐4me $25 registra4on fee is required for each camper for the 2015 camp season (includes-­‐T-­‐shirts). Camp hours: 7:30a – 5:00p June 1 – August 7, 2015. Late pick up fee (a`er 5:30pm) is $15 per hour per camper. Child’s Name:____________________________________________Age:_______ Shirt Size: Youth □S □M □L Parent’s Name:___________________________________________Phone:____________________________ Home Phone(s):_______________________________ Cell Phone(s):__________________________________ Guardian(s):___________________________________________ Rela4on to Child:______________________ Address : _________________________________________________________________________________ Work Phone(s):_____________________________________________________________________________ Email: ___________________________________________________________________________________ 3. Camp ac(vi(es (tenta(ve calendar) are a4ached. Please put a line through ac(vi(es which you choose for your child to not a4end or par(cipate in. A one-­‐(me $100 fee is required for each camper for the 2015 camp season and is due prior to child a4ending camp. Deadline for payment is June 1, 2015. Authorization and Consent
As parent, legal guardian or agency representing the child named above, I hereby give consent to enroll
my child in the specified program(s) operated by Reach Out and Touch. I have enclosed the proper
deposit and will complete all payments and forms by the stated deadlines. All scheduled events are
subject to change. I understand that no fees will be refunded or transferred unless a child is unable to
participate due to an accident or illness per physician orders. I recognize that my child must follow
safety instructions, remain in areas designated by staff, and refrain from behavior that is harmful to
him/her or others. Failure to do so will result in dismissal from program without refund. Reach Out and
Touch staff will do its best to ensure a safe experience, however I understand that accidents do occur.
I hereby release Reach Out and Touch from any and all responsibility and liability of any nature
resulting in my child’s participation in any program accident including claims for any injury, illness, loss
or damage. My signature gives Reach Out and Touch permission to use all photos and videos taken
during programs for promotional purposes. To opt out of this, I will submit request in writing. I have
informed camp staff of my child’s medical conditions. All information given is accurate and true to the
best of my knowledge.
Parent/Guardian Signature: ________________________________________ Date: __________
Emergency Contact:___________________________ Phone:______________________________
In the event that neither I nor my designee cannot be contacted at the time of a medical emergency, I
consent to emergency treatment determined necessary by a qualified physician.
Parent/Guardian signature:_______________________________Date:______________________
CHILD INFORMATION SHEET
Child’s Name:____________________________ Date of Birth:___________________________
Parent/Guardian Name: ___________________________________________________________
Address: _____________________________________________________________________
Phone: __________________________ Email: ________________________________________
HEALTH HISTORY OF CHILD: This is kept confidential.
Attach additional sheet if necessary
Please list any allergies:___________________________________________________________
Describe your child’s allergic reaction:________________________________________________
Other medical concerns:___________________________________________________________
Medications being used:___________________________________________________________
Please note that Reach Out and Touch cannot dispense any medications. Do not send any medications to camp with your child.
Does your child wear: glasses( ), contact lenses( ), hearing aid( ), corrective shoes( ), prosthesis( )?
Any other information concerning your child’s health that we should be aware
of:___________________________________________________________________________
Child’s Physician: ___________________________________Phone #_______________________
Child’s Dentist:____________________________________ Phone #_______________________
My child has no condition that would prevent him/her from participating in the program or that the
program’s normal activities would aggravate: Yes( ), No( ). If yes, explain in detail on an attached additional sheet.
Is your child up-to-date on all state-required immunizations? Yes No
Is the participant covered by family medial/hospital insurance? Yes No
INSURANCE INFORMATION
Is the participant covered by family medial/hospital insurance? Yes No
Carrier or Plan Name: _____________________ Group #: _____________________
Address _______________________ City _____________________State ______ Zip Code ________
Name of Insured: _________________________
Relationship to participant: ___________________
RELEASE INFORMATION:
Under no circumstances will a child be released to anyone without your written authorization.
release to the following individuals.
Photo identification is required for
I give authorization for the following people to pick my child up from Reach Out and Touch’s programs:
Name:_________________________Relationship:____________Phone:_____________________
Name:_________________________Relationship:____________Phone:_____________________
If applicable, please specify any individuals for whom there is a restraining order or custody restriction:
_____________________________________________________________________________
Unless we have a copy of a court order prohibiting the release of a child to one of the child’s parents, it is legal for your child to be
released to either parent.
**CAMP WILL BE HELD AT Liberty Church, 6703 Melara Avenue, Shreveport, L A. 71108**
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Central Office: Reach Out and Touch, 3017 West 70 Street, Shreveport, LA 71108